| Engineer Contact Information |
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| 1. Please provide the following contact information: |
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| Full Name |
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| Professional designation |
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| License Number in Ontario |
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| Company Information (If applicable) |
| Company Name |
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| Position |
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| Complete adress/postal code |
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| Telephone number |
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| Fax number |
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| Email address |
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| Home Information |
| Address/postal code |
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| Telephone number |
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| Fax number |
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| Email address |
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| 2. Which location would you prefer the EIR program office use? |
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| Professional Information |
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| 3. Please list your college and university degrees with area of specialty and dates received. |
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| 4. In total, how many years of engineering experience do you have? |
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| 5. Are you currently… |
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If other, please specify:
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| Location and Availability |
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| 6. Please list the community/district (in order of preference) for your assigned school. (Please specify up to 3 locations) |
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| 7. How many hours a week in total (prep time, onsite, etc.) are you willing to spend? (Please specify number of hours below) |
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| 8. Have you already received permission from your employer to participate in this program? |
Yes (please go to Q. 11)
No (please go to Q. 9)
Not applicable (please go to Q. 11)
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| 9. Do you require assistance from the EIR Program to obtain permission to participate in this program? |
Yes (please go to Q. 10)
No (please go to Q. 11)
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| 10. If necessary, whom would you like us to contact? (Please provide information below) |
| Name |
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| Position |
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| Telephone |
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| Youth Experience |
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| 11. Have you had any recent experiences working with young people (e.g., children’s clubs, guides, scouts, coaching, etc.)? |
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If yes, please give a few examples
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| 12. Have you had any formal experience giving presentations/teaching to children and/or teenagers? |
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If yes, please give a few examples
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| EIR Program Information |
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| 13. How did you first hear about the EIR program? |
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| 14. Would you prefer to be an EIR at a(n)… |
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| 15. Why do you want to be involved in the EIR program? |
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| 16. The EIR program requires that all volunteers working with children undergo a basic police check. Do you have any objections to this? |
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| Name/Signature |
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| Date |
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